Peri-operative corticosteroids to prevent iatrogenic adrenal insufficiency: are the doses used too high?

Abstract

Background Optimal peri-operative corticosteroid dosing to avoid excess or deficiency for patients taking chronic prednisone (c-PRED) is unknown. Methods In a randomized double-blind trial, traditional doses of IV hydrocortisone (HC) were compared to lower doses matched to patients' c-PRED dose. Patients taking ≥G5mg c-PRED for ≥G2 wks within 15 mg/day) preoperatively then q8h X24h (LD). Low dose (1 mcg) co-syntropin stimulation test assessed adrenal function. Results Among 70 subjects (mean c-PRED exposure 1,870 mg/6 months), inflammatory bowel diseases (39%) and connective tissue disorders (36%) commonly led to abdominal (43%) and joint replacement (30%) procedures, respectively. Co-primary outcome measures, adrenal insufficiency and corticosteroids excess scales, did not meaningfully differ between LD and TD, although AIS trends favored TD. Blood pressure was lower following surgery in LD: 109/63 vs TD: 120/69 (SBP: p=0.01; DBP: p=0.04) and hypotension was more common in LD (58% vs TD: 29%; p=0.01). Post-operative infections and wound healing did not differ. Conclusions Lower doses of peri-operative HC may lead to more hypotension in the post-operative period. However, only 1–2 higher HC doses may be required. Larger trials are needed to assess impact on post-operative wound healing and infections. Clinical Pharmacology & Therapeutics (2004) 75, P76–P76; doi: 10.1016/j.clpt.2003.11.287